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Based on observation and staff interview, in five (5) of five (5) Operating Rooms, the facility failed to ensure that staff provided care in accordance with acceptable Standards of Infection Control Practices and facility Policies and Procedures, to avoid potential sources of cross contamination.

This lapse in infection control practice may have placed all patients at risk for exposure to hospital acquired infections.

Findings:

See Citation: Tag A 749.

Based on observation, document review and interview, in five (5) of five (5) Operating Rooms (OR), the facility failed to ensure that the proper surgical attire was worn and used correctly by the OR staff.

Findings:

Observation in the facility's Pediatric Operating Room (OR) Suites during a tour between 11:10 AM and 12:40 PM, on 12/01/15, identified the following failures by staff to comply with the facility's policy on OR attire:

In OR #4: a Resident physician in the sterile field had approximately four (4) inches of hair above the nape of the neck and uncovered sideburns. A Surgeon in the sterile field had approximately three (3) inches of uncovered hair above the nape of the neck. A Circulating Nurse had uncovered earrings and another Nurse had uncovered sideburns. An Anesthesiologist did not wear gloves when making adjustments to the Laryngeal Mask Airway hoses attached to the patient.

In OR # 5: a Nurse in the sterile field had approximately two (2) inches of uncovered hair above her forehead. A Resident, a Surgeon and an Anesthesiologist all had approximately three (3) inches of uncovered hair above the nape of their necks. An Anesthesiologist had uncovered sideburns.

In OR # 6: a Nurse had uncovered studded earrings, a Surgeon had approximately three (3) inches of uncovered hair above the nape of his neck. A Surgical Technician had the sides of his beard and an Anesthesiologist had approximately three (3) inches of uncovered hair above the nape of his neck.

Similar findings were observed in OR #7 and OR # 8.

These findings were acknowledged by Staff #1 the Nursing Director Perioperative Services, Staff #2 the Patient Care Director Perioperative Services, Staff #3 Clinical Nurse Specialist for the Perioperative Department, and Staff #4 the Administrative Executive Director of Patient Care Services, who accompanied the State Agency Surveyor during the tour.

Staff #1 stated on 12/01/15 at 12:15 PM, "the staff are not adhering to the policy, we have plenty of hoods and head coverings here but they just aren't using them."

Staff #2 stated on 12/01/15 at 12:25 PM, "Jewelry shouldn't be seen, the staff needs to remove the jewelry."

Both Staff #1 and #2 stated on 12/01/15 at 12:35 PM, "the physician should have worn gloves when making adjustments to the Laryngeal Mask Airway hoses attached to the patient."

Review of the facility's Policy and Procedure titled "PERIOP/BUS 110 Attire in the Perioperative, and Labor and Delivery Areas", last revised 02/14, stated:
"Restricted Area: Includes the OR and the procedure room, the clean core and scrub sink areas.
Semi-Restricted Areas: Include operating room hallways with direct access to the OR's.
All persons entering the OR rooms or Semi-Restricted Areas of the Perioperative Suites must cover head with a disposable bouffant and all facial hear, including sideburns and necklines and must be covered with either a clean hood or mask.
Jewelry that cannot be contained within clothing in the restricted area should not be worn."

The Policy did not define the usage of non-sterile gloves for patient interventions in the restricted and semi restricted areas.